Provider Demographics
NPI:1396893764
Name:HOLZER, MARK J (DDS, RPH)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:HOLZER
Suffix:
Gender:M
Credentials:DDS, RPH
Other - Prefix:DR
Other - First Name:M.
Other - Middle Name:J
Other - Last Name:HOLZER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS, RPH
Mailing Address - Street 1:2116 ROBINWOOD LN
Mailing Address - Street 2:
Mailing Address - City:RIVERWOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60015-1412
Mailing Address - Country:US
Mailing Address - Phone:847-940-0451
Mailing Address - Fax:
Practice Address - Street 1:241 GOLF MILL CTR
Practice Address - Street 2:SUITE 812
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-1224
Practice Address - Country:US
Practice Address - Phone:847-298-5885
Practice Address - Fax:847-298-2938
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0211311223G0001X
IL051-039887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No183500000XPharmacy Service ProvidersPharmacist